Assessing the Outcome of Holmium Laser Enucleation of the Prostate by Age,Prostate Volume,and a History of Blood Thinning Agents: Report from a Single-Center Series of >1800 Consecutive Cases

Abstract

Purpose:

To assess perioperative outcomes of holmium laser enucleation of the prostate (HoLEP) in a real-world scenario and with a focus on demanding patient factors, such as large prostate size, advanced patient age, and anticoagulation therapy (AT).

Materials and Methods:

We retrospectively analyzed HoLEP procedures at our institution between 2010 and 2016. After stratification by prostate volume, age, and AT, perioperative and early voiding characteristics were compared. A multivariable regression model was employed to identify predictors of prolonged time of catheterization (defined as being above group's median).

Results:

The study cohort consisted of 1816 men with a median age of 71 years (interquartile range [IQR]: 66–76), a median prostate volume of 80 mL (IQR: 58–105), and American Society of Anesthesiologists score ≥3 in 618 men (34%). Median time of enucleation and morcellation was 43 minutes (IQR: 31–60) and 10 minutes (IQR: 6–18), respectively. Perioperative blood transfusions were administered in 44 (2.4%) cases, severe postoperative complications (Clavien–Dindo grade ≥3b) occurred in 61 (3.3%) cases. The median time of catheterization was 2 days (IQR: 2–2), with prolonged catheterization occurring in 277 (15%) cases. After adjustment, large prostates (fourth volume quartile [106–280 mL]) (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.3–2.6, p = 0.001), therapeutic low-molecular-weight heparin bridging regimen (OR: 2.2, 95% CI: 1.4–3.6, p = 0.037), low-dose acetylsalicylic acid (OR: 1.5, 95% CI: 1.0–2.2, p = 0.015), and a history of direct oral anticoagulation (OR: 2.3, 95% CI: 1.2–4.0, p = 0.022), but not patient age, were independently associated with prolonged catheterization.

Conclusions:

We confirm HoLEP as safe and efficient; however, patients with large prostates and patients with a history of AT are at risk of prolonged catheterization.

Introduction

Transurethral resection of the prostate (TURP) had long been the surgical gold standard¹ in treating lower urinary tract syndrome (LUTS) secondary to benign prostatic enlargement (BPE) in patients not tolerating medical treatment or with refractory symptoms. It is however limited by prostate size and resection time, and carries non-neglible perioperative morbidity, including bleeding, TURP syndrome, or recurrent BPE.² As a possibility to address these limitations, holmium laser enucleation of the prostate (HoLEP) was introduced in 1998 by Gilling and Frauendorfer^3,4 and has since become a guideline-endorsed standard of care for the treament of large prostates (>80 mL).^2,5 Nevertheless, despite level one evidence of superior efficacy, safety, and cost effectiveness of HoLEP over TURP and open adenomectomy, a wider acceptance of HoLEP has been hampered, possibly due to initial costs or an allegedly unfavorable learning curve.⁶ As such, only few reports exist on single-center experiences in performing HoLEP,^6
–8 aside the evidence from a number of randomized controlled trials.⁹ However, the latter studies often include a patient selection that might not be representative of a real-world experience, yet, at an ever-increasing proportion of elderly patients in western populations, a greater number of men are undergoing HoLEP with larger prostate size, at a greater age.^10
–12 Given the probability of comorbidities and reduced physiologic reserve, outcomes tailored to this population merit further study.¹³

Against this backdrop, we aimed to report on our single-center, high-volume experience and furthermore, to provide an in-depth analysis on the impact of prostate size, patient age, as well as anticoagulation therapy (AT) within a real-world scenario.

Materials and Methods

Study population and patient characteristics

This was a local Ethics Committee of Hamburg (No. PV5633)-approved observational study. Relying on our institutional database, we retrospectvely identified 1816 consecutive patients who underwent HoLEP for LUTS from 2010 to 2016. Patient characteristics recorded included patient age, American Society of Anesthesiologists score, body mass index, serum prostate-specific antigen (PSA, ng/mL), transrectal ultrasound-determined prostate size (mL), presence of indwelling catheters, previous desobstructive prostate surgery, concurrent medication (AT, desobstructive medication), as well as pre- and postoperative subjective and objective voiding characteristics, including International Prostate Symptom and Quality-of-Life scores, postvoid residual volume (PVR, mL), pre- vs postoperative PVR difference (ΔPVR), maximum flow rate (Qmax in mL/s), pre- vs postoperative Qmax difference (ΔQmax), and failure to void necessitating discharge with an indwelling catheter. Perioperative and procedural characteristics included enucleation and morcellation time in minutes, retrieved enucleated specimen weight in grams (determined in the operating room), difference in pre- vs postoperative hemoglobin nadir (ΔHb), perioperative blood transfusions, time of catheterization, prolonged catheterization (defined as being above the groups median), and postoperative complications. Postoperative complications were recorded and graded according to the Clavien–Dindo Classification (CDC).¹⁴

Intervention

All prostatic adenomas were enucleated using a one-, two-, or three-lobe technique as previously described¹⁵ and cases were performed or supervised by expert surgeons (caseload >50/year), totalling seven surgeons. The 100 W holmium laser generator (VersaPulse; Lumenis, Palo Alto, CA) was used at 70 W with settings of 1.4 J and a frequency of 50 Hz through 550 μm end-firing laser fibers (Lumenis). For enucleation, a 27F continuous flow resectoscope with a laser bridge adapter and an endoscopic camera (Olympus) was used. The enucleated tissue was removed with the Lumenis morcellator device over a 26F nephroscope. All specimens were histopathologically evaluated by a pathologist with urogenital expertise. The weight of the removed tissue was routinely measured and documented. All patients received perioperative antibiotic prophylaxis. After the intervention, the patients received a 22F irrigation catheter and the bladder was irrigated for 24 hours with saline solution before the catheter was removed 48 hours postoperatively according to our institutional standard. After catheter removal, uroflowmetry outcomes and PVR measurement were recorded for all patients.

Our institutional standard for management of AT was as follows: Patients receiving a direct oral anticoagulation (DOAC) ceased therapy 48 hours before surgery. All patients on coumarins paused the drug 7–10 days before surgery. These patients were bridged using bodyweight-adapted low-molecular-weight heparin (LMWH) based on their individual international normalized ratio threshold and CHA₂DS₂-VASc score based on thrombembolic risk. LMWH was stopped 24 hours before surgery. With regard to antiplatelets, patients continued low-dose acetylsalicylic acid (AsA), while adenosine diphosphate (ADP) receptor antagoinsts were exchanged for low-dose AsA whenever possible. In select cases (i.e., presence of artificial heart valves, coagulation disorders), AT was managed individually after consultation with our institutional cardiology and/or coagulation specialist. In any case, coumarins, DOAC, and ADP antagonists were restarted after 14 days of LMWH bridging.

Statistical analyses

Descriptive statistics were reported using medians and interquartile ranges (IQRs) or means and standard deviations for continuous variables, and frequencies and proportions for categorial variables. Pearson's chi-squared and analysis of variance tests were used as appropriate for comparison of categorical and continuous variables between the groups.

Our analyses proceeded in the following steps. First, preoperative patient characteristics were listed. Second, the cohort was stratified by prostate volume (quartiles), age (decades), and AT. Perioperative and procedural as well as voiding characteristics were listed and compared. Third, a multivariable logistic regression model was fitted to identify independent predictors of prolonged catheterization, which was chosen as a surrogate parameter of an aggravated course.¹⁷ A surrogate endpoint was chosen a priori to avoid overfitting of the multivariable model as the anticipated frequency of alternative adverse events (i.e., blood transfusion rate or severe postoperative complications) was low. Bootstrap correction (100 samples) was applied in multivariable regressions to account for optimistic prediction.⁹ All statistical testing was two sided with a level of significance set at p < 0.05. Analyses were performed using Stata (StataCorp. 2015, Stata Statistical Software: release 14; StataCorp LP, College Station, TX).

Results

Baseline characteristics

The group's mean age was 71 years (IQR: 66–76), with 184 (10%) men being 80 years of age or older. At a median prostate volume of 80 mL (IQR: 58–105) the cohort's median PSA was 5.3 ng/mL (IQR: 2.8–10). Severe systemic disease (ASA score ≥3) was present in n = 618 (34%) of men. Regarding AT, 458 (25%) patients were operated on low-dose AsA, 135 (7.4%) perioperatively received therapeutic LMWH. Fifty-five (3.0%), 43 (2.4%), and 122 (6.7%) of patients had a history of DOAC, ADP antagonists, and coumarins, respectively (Table 1).

Table 1.

Overall Preoperative and Voiding Characteristics in 1816 Men Undergoing Holmium Laser Enucleation of the Prostate for Obstructive Lower Urinary Tract Symptoms

Age (years); median (IQR)	71 (66–76)
Age groups; n (%)
≤60	134 (7.4)
60–69	636 (35)
70–79	862 (48)
≥80	184 (10)
ASA score; n (%)
1	136 (7.5)
2	1007 (56)
3	601 (33)
4	17 (0.9)
Unknown	55 (3.0)
BMI; median (IQR)	26 (24–29)
PSA (ng/mL); median (IQR)	5.3 (2.8–10)
Prostate volume (mL); median (IQR)	80 (58–105)
Prostate volume (quartiles); n (%)
First quartile (20–57 mL)	454 (25)
Second quartile (58–80 mL)	532 (29)
Third quartile (81–105 mL)	382 (21)
Fourth quartile (106–280 mL)	448 (25)
Presence of indwelling catheter; n (%)	641 (35)
Previous prostate surgery; n (%)
TURP or greenlight laser vaporization	31 (1.7)
Medication; n (%)
Low-dose aspirin	458 (25)
ADP antagonists	43 (2.4)
DOAC	55 (3.0)
Coumarins	122 (6.7)
Therapeutic LMWH	135 (7.4)
α-blockers	1196 (66)
5α-Reductase inhibitors	345 (19)
Preoperative voiding characteristics
I-PSS	19 (13–24)
QoL	4 (3–5)
PVR (mL); median (IQR)	78 (26–140)
Qmax (mL/s); median (IQR)	10 (7–14)

Percentages may not add up to 100%, as they are rounded.

IQR = interquartile range; ASA = American Society of Anesthesiologists; BMI = body mass index; TURP = transurethral resection of the prostate; LMWH = low-molecular-weight heparin; DOAC = direct oral anticoagulation; ADP = adenosine diphosphate; IPSS = International Prostate Symptom Score; QoL = quality of life; PVR = postvoid residual volume; PSA = prostate-specific antigen; Qmax = maximum urinary flow rate.

Perioperative and procedural characteristics

The cohort's median enucleation and morcellation time was 43 minutes (IQR: 31–60) and 10 minutes (IQR: 6–18), respectively, while the median enucleated specimen weight was 50 g (IQR: 30–76). The median ΔHb was 1.2 g/dL (IQR: 0.6–2), with 44 (2.4%) of patients receiving blood transfusions. Overall, severe (CDC ≥3b) postoperative complications occurred in 61 (3.3%) cases. The median time of catheterization was 2 days (IQR: 2–2), an event of prolonged catheterization (>2 days) occurred in 277 (15%) of cases (Table 2).

Table 2.

Perioperative Characteristics of 1816 Men Undergoing Holmium Laser Enucleation of the Prostate for Obstructive Lower Urinary Tract Symptoms in the Overall Cohort As Well As Stratified According to Prostate Volume (Quartiles), Age (Decades), and Anticoagulation Therapy

	Prostate volume (quartiles)
	Overall	First (20–57 mL)	Second (58–80 mL)	Third (81–105 mL)	Fourth (106–280 mL)	p-Value
Patients; n (%)	1816 (100)	454 (25)	532 (29)	382 (21)	448 (25)
Enucleation time (minutes); median (IQR)	43 (31–60)	33 (21–45)	41 (30–57)	48 (35–65)	55 (43–74)	<0.001
Morcellation time (minutes); median (IQR)	10 (6–18)	6 (4–9)	9 (6–13)	12 (8–19)	20 (13–31)	<0.001
Enucleated specimen weight (g); median (IQR)	50 (30–76)	24 (15–34)	42 (30–55)	63 (48–80)	90 (69–112)	<0.001
ΔHb (mg/dL); median (IQR)	1.2 (0.6–2.0)	0.9 (0.4–1.6)	1.1 (0.5–1.8)	1.3 (0.8–2.0)	1.5 (0.9–2.4)	<0.001
Perioperative blood transfusion; n (%)	44 (2.4)	11 (2.6)	10 (2.0)	9 (2.5)	13 (3.1)	0.7
Severe postoperative complication (CDC grade ≥3b); n (%)	61 (3.3)	9 (2.0)	16 (3.0)	16 (4.2)	20 (4.5)	0.3
Prolonged catheterization; n (%)	277 (15)	56 (12)	70 (13)	64 (17)	87 (19)	0.009

	Age (decades)
	Overall	<60 Years	60–69 Years	70–79 Years	≥80 Years
Patients; n (%)	1816 (100)	134 (7.4)	636 (35)	862 (48)	184 (10)
Enucleation time (minutes); median (IQR)	43 (31–60)	38.5 (25–53)	43 (30–59)	45 (32–63)	44 (31–60)	0.01
Morcellation time (minutes); median (IQR)	10 (6–18)	8.5 (5–13)	10 (6–17)	11 (6–19)	10 (7–20)	0.007
Enucleated specimen weight (g); median (IQR)	50 (30–76)	40 (21–63)	50 (30–77)	50 (31–78)	51.5 (32–80)	0.005
ΔHb (mg/dL); median (IQR)	1.2 (0.6–2)	1.1 (0.5–1.8)	1.2 (0.6–1.9)	1.3 (0.6–2)	1.2 (0.7–2.3)	0.02
Perioperative blood transfusion; n (%)	44 (2.4)	0 (0)	8 (1.3)	22 (2.7)	14 (8.2)	<0.001
Severe postoperative complication (CDC grade ≥3b); n (%)	61 (3.3)	2 (1.5)	12 (1.9)	34 (3.9)	13 (7.1)	0.02
Prolonged catheterization; n (%)	277 (15)	17 (13)	92 (15)	127 (15)	41 (22)	0.04

	AT
	None	Low-dose aspirin	Therapeutic LMWH	DOAC	ADP antagonists
Patients; n (%)	1133 (65)	458 (25)	135 (7.4)	55 (3)	43 (2.4)
Enucleation time (minutes); median (IQR)	44 (31–62)	43 (30–59)	42 (30–56)	38 (26–48)	39 (29–53)	0.1
Morcellation time (minutes); median (IQR)	10 (6–18)	10 (6–17)	10 (6–20)	8.5 (6–16)	10 (5–15)	0.4
Enucleated specimen weight (g); median (IQR)	50 (30–76)	46 (28–57)	50 (28–78)	56.5 (33–74)	50.5 (35–80)	0.7
ΔHb (mg/dL); median (IQR)	1.2 (0.6–1.9)	1.2 (0.5–1.8)	1.3 (0.6–2.5)	1.2 (0.8–2.2)	1.3 (0.9–2.1)	0.007
Perioperative blood transfusion; n (%)	25 (1.7)	11 (2.4)	15 (11)	3 (5.5)	3 (7.0)	<0.001
Severe postoperative complication (CDC grade ≥3b); n (%)	37 (2.3)	13 (2.8)	17 (13)	7 (13)	6 (14)	<0.001
Prolonged catheterization; n (%)	217 (14)	73 (18)	40 (30)	18 (33)	11 (25)	<0.001

AT = anticoagulation therapy; ΔHb = difference in pre- vs postoperative nadir hemoglobin level; CDC = Clavien–Dindo Classification (≥3b = requiring surgical, endoscopic, or radiological intervention under general anesthesia).

Stratification by prostate volume revealed significant differences with respect to enucleation and morcellation time, specimen weight, ΔHb, and prolonged catheterization in that all characteristics increased with prostate size (all p < 0.001). For example, time of enucleation was 33 minutes (IQR: 21–45) vs 55 minutes (IQR: 43–74) in the first (20–48 mL) vs fourth (106–280 mL) prostate volume quartile. Similarly, prolonged catheterization occurred in 56 (12%) and 87 (19%) of patients of the first and fourth prostate volume quartile, respectively. However, no significant differences were observed with respect to blood transfusion rates and CDC complications. Stratification by age revealed significant differences, with all characteristics increasing with age (all p ≤ 0.04). For example, prolonged catheterization occurred in 17 (13%) and 41 (22%) of patients <60 years and ≥80 years, respectively. Lastly, stratification by AT revealed no significant differences with respect to procedural characteristics, but ΔHb, blood transfusion rate, CDC complications, and prolonged catheterization, all of which were greater among patients on AT (all p < 0.001). For example, prolonged catheterization affected 40 (30%) patients receiving therapeutic LMWH, and 18 (33%) with a history of DOAC, compared with 217 (13%) patients without AT (Table 2).

Voiding characteristics

The overall median ΔPVR was 85 mL (IQR: 30–155), and median ΔQmax 12 mL/s (IQR: 5.0–21). A failure to void occurred in 59 men (3.4%), who were discharged with an indwelling transurethral catheter.

Stratification by prostate volume revealed no statistically significant differences in voiding characteristics, with ΔPVR, ΔQmax, and failure to void almost evenly distributed among the strata (all p ≥ 0.3). Conversely, significant differences were observed among all age strata. Specifically, improvement of PVR (ΔPVR) was more pronounced in older men (85 mL [IQR: 35–180] in men <60 years vs 100 mL [IQR: 34–233] in men ≥80 years), improvement of maximal flow rate (ΔQmax) was more pronounced in younger patients (18 mL/s [IQR: 9.0–27] in men <60 years vs 12 [IQR: 3.5–18] in men ≥80 years). A postoperative failure to void was observed more frequently in older patients (4.5% of men <60 years vs 6.5% of men ≥80 years) (all p ≤ 0.01). Lastly, patients receiving AT differed significantly with respect to ΔPVR (p = 0.048), but no significant differences were observed with resepect to ΔQmax and failure to void (Fig. 1).

FIG. 1.

Overall, as well as prostate size (volume quartiles), age (decades), AT therapy stratified postoperative voiding characteristics of 1816 men undergoing HoLEP for obstructive lower urinary tract symptoms. (A) ΔPVR (mL), median (IQR). (B) ΔQmax (mL/s), median (IQR). (C) Failure to void (n, [%]). ΔPVR = pre- vs postoperative PVR difference, ΔQmax = pre- vs postoperative maximum uroflowmetry (Qmax) difference. AT = anticoagulation therapy; HoLEP = holmium laser enucleation of the prostate; IQR = interquartile range; PVR = postvoid residual volume.

Multivariable analysis predicting prolonged catheterization time

On bootstrap-corrected, multivariable logistic regression analysis, a large prostate volume (fourth prostate volume quartile [106–280 mL], odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.3–2.6, p = 0.001), a history of low-dose AsA (OR: 1.5, 95% CI: 1.0–2.2, p = 0.015), therapeutic LMWH (OR: 2.2, 95% CI: 1.4–3.6, p = 0.037), and DOAC intake (OR: 2.3, 95% CI: 1.2–4.0, p = 0.022), but not patient age, were independently associated with prolonged catheterization (Table 3).

Table 3.

Multivariable Logistic Regression Analysis^a Predicting Prolonged Catheterization^b Among 1816 Patients Undergoing Holmium Laser Enucleation of the Prostate

Variables	OR	95% CI	p-Value
Age (years)
≤60	Ref
60–69	0.9	0.6–1.5	0.8
70–79	0.8	0.5–1.4	0.4
≥80	1.2	0.6–2.5	0.5
ASA score
1	Ref
2	1.5	0.8–2.5	0.2
3	1.6	0.9–2.6	0.09
4	1.2	0.3–5.4	0.8
Prostate volume (quartiles)
First quartile (20–57 mL)	Ref
Second quartile (58–80 mL)	1.1	0.7–1.7	0.5
Third quartile (81–105 mL)	1.5	0.9–2.3	0.064
Fourth quartile (106–280 mL)	1.8	1.3–2.6	0.001
Preoperative indwelling catheter (vs no catheter)	1.1	0.8–1.5	0.3
Anticoagulation therapy
Low-dose aspirin (vs negative)	1.5	1.0–2.2	0.015
Therapeutic LMWH (vs negative)	2.2	1.4–3.6	0.037
DOAC (vs negative)	2.3	1.2–4.0	0.022
ADP antagonists (vs negative)	1.3	0.5–2.8	0.3

Bootstrap-corrected (100 repetitions).

Above group's median (2 days), n = 277 events (15%).

OR = odds ratio; CI = confidence interval.

Discussion

Despite level 1 evidence of a superior efficacy,⁵ HoLEP dissemination has been limited—as witnessed by a small number of single-center reports.^6
–8 Against this backdrop, we aimed to provide a meticulous report on our series of more than 1800 cases of HoLEP, including 184 octogenarians, over 400 patients with prostates over 100 mL, and over 600 patients with a history of AT. Several of our findings merit further discussion.

First, we confirm HoLEP as feasible and effective regardless of age. Of note, the association of patient age and HoLEP efficacy/safety has been scarcely explored to date.^11,18,19 Existing studies—although cohort sizes and differences in reporting somewhat hinder comparison—conclude on HoLEP as equally effective, irrespective of age. Importantly, differences are observed with respect to complications. Mmeje and colleagues, in a cohort of 45 octogenarians, noted a blood transfusion rate of 11%,¹⁸ whereas Piao and associates (38 patients) and Elshal and colleagues (264 patients) report CDC ≥3 complications of 16% and 18%, respectively.^11,19 We too did observe increasing transfusion and complication rates with age, most pronounced among men ≥80 years (8.2% and 7.1%, respectively), which at first glance might cause reluctance to perform the procedure. However, after adjustment for comorbidities, medication and prostate volume in our multivariable model, age was no longer associated with the event of prolonged catheterization.

While our data confirm safety of HoLEP in elder men, they also corroborate a significant and clinically meaningful improvement in early functional outcome across all age strata. For example, in the subgroup of octogenarians (≥80 years, n = 184) more than half (55%) presented with an indwelling catheter upon admission, whereas 12 (6.5%) failed to void and were discharged with an indwelling catheter. In this context, it ought to be noted that long-term catheterization, aside patient dependency, and risk for severe sepsis and noninfectious complications poses a significant financial burden with monthly costs exceeding 100 Euros per patient in certain scenarios.^20,21 Taken together, we believe our data, which support good short-term functional outcome regardless of age, may help clinicians hesitant to perform HoLEP in elderly men weigh the possible benefits of the procedure in carefully selected patients.

Second, we corroborate that HoLEP can safely be performed and offers excellent early functional outcome, regardless of prostate size.^8,22,23 Specifically, while procedural characteristics such as time of enucleation and morcellation increased proportionally among the volume strata, blood transfusion and complication rates did not differ significantly. The blood transfusion rate of 3.1% observed in our fourth volume quartile (106–280 mL) is greater than in some single-surgeon HoLEP series,^22,23 but comparable to recent multicenter series. For example, Romero-Otero and colleagues in their HoLEP series observed a blood transfusion rate of 5.8% (n = 362) in prostates ≥100 mL.⁸ To provide further perspective, it ought to be noted that our frequency of adverse events lies well below those published from large TURP series, with transfusion and surgical revision rates of 9.5% and 8.2% among prostates >60 mL.² The fact that ΔHb did increase significantly with prostate size, but not transfusion rate, corresponds with the clinical impression that prolonged postoperative hematuria occurs in larger prostates but is managable conservatively with prolonged irrigation. Indeed, very large prostates (fourth volume quartile, 106–280 mL) were confirmed as independent prognosticators of prolonged catheterization in our multivariable regression. This finding has also been observed in studies that assessed prostate size-stratified perioperative outcomes, such as Shah and colleagues, who reported time of catheterization to be almost twice as long in cohorts of <60 mL and >100 mL prostate volume (24 hours vs 43 hours, p < 0.001).²²

Third, we found severe complications and blood transfusions to be significantly more common among patients with a history of DOAC and ADP antagonist intake, or on a LMWH bridging regimen, whereas procedural characteristics and early functional outcome did not differ significantly among the groups. Evidence for HoLEP under anticoagulation and antiplatelet therapy is limited to retrospective data from heterogeneous cohorts.^16,24
–26 Depending on the bridging regimen and predominant anticoagulation or antiplatelet therapy, transfusion rates similar to ours of up to 8%^24,26 or even greater (21%) are being reported.⁸ Furthermore, our report, to the best of our knowledge, is the second to report on DOAC intake in patients undergoing HoLEP.²⁷ Our findings are in line with Becker and colleagues,²⁷ who in a cohort of 94 patients on DOAC—as compared with patients not receiving blood thinning agents—found significantly longer catheterization time (2.2 days [mean] and 2.6 days [mean], p < 0.001), tamponades or bleeding requiring intervention (7.9% and 3.9%, respectively, p < 0.003). The analysis was, however, not confirmed in a multivariable model. Clinically, our data raise concern, as DOACs are increasingly being prescribed and it is estimated that 8%–10% of elderly receive such medication.²⁸ While it is possible that renal function may have impacted the metabolization of DOAC, or that there was an incongruence in perioperative management (patients may simply have failed to pause medication as recommended) it may also be that the recommendation of perioperative DOAC management, which stems from nonurological procedures, ought to be adapted to the specifics of endourological prostate surgery.²⁷

Our study has some limitations, including its retrospective data collection and review. As such, the granularity of preoperatively known and complicating factors of LUTS (e.g., neurological disease, urodynamically proven detrusor underactivity) and consequently postoperative outcomes were limited and prevented us to decidedly address these possible confounders. Furthermore, while we believe that providing a multivariable model essentially strengthened our exploratory descriptive analyses, the choice of a surrogate endpoint may have under- or overestimated the impact of certain variables. Lastly, our report focused on a detailed assessment of perioperative outcomes and does not provide long-term follow-up on functional outcome and late complications, such as bladder neck contracture or urethral stricture.

Conclusions

In conclusion, in our single-center experience of >1800 cases, we confirm HoLEP as an efficacious treatment with an overall low complication rate. Furthermore, functional outcomes are equally improved in demanding cases such as large prostates, octogenarians, and patient on therapeutic LMWH and DOAC.

Footnotes

Author Contributions

All authors meet the criteria for authorship.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding information was received.

Abbreviations Used

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